Improvements in Laparoscopic Treatment for Complicated Appendicitis

Introduction

Laparoscopic appendectomy has become established as the treatment of choice for acute appendicitis. Multiple studies have demonstrated that there is less pain, shorter hospital stay, and quicker return to full activities following laparoscopic appendectomy when compared with open appendectomy.^1–8 Laparoscopic appendectomy for complicated appendicitis remains controversial. Although most studies have shown an advantage for laparoscopic appendectomy, others have shown a decrease in complications for perforated appendicitis treated by open appendectomy.^6,8–14 Early in this institution's experience with laparoscopic appendectomy, we published our results for laparoscopic appendectomy in complicated appendicitis and offered a word of caution. ¹⁵ In that study, we found that hospital stay averaged 7 days, and morbidity was 42%. We concluded that laparoscopic appendectomy could be performed safely but did not prevent the associated infectious complications that occur with complicated appendicitis.

In the ensuing 15 years since that original study, several advances in laparoscopic surgery have occurred. These include improvement in trocars, development of wound protection devices, improved video optics, and laparoscopic stapling equipment for the division and sealing of tissue. Coinciding with this time frame, the learning curve of laparoscopic surgery has flattened. Advanced laparoscopic techniques now permit an ever-increasing application of laparoscopy to abdominal surgery. Two-handed dissection has become a standard practice and permits the coordinated effort of a single rather than multiple surgeons.

In addition, there have been advances in antimicrobial therapy over the last 15 years. Several broad-spectrum antibiotics are available in oral form and permit earlier transition of antibiotic therapy to an outpatient setting. Home health agencies are much more commonplace and allow for patient assessment and assistance after dismissal from the hospital.

All of these advances should translate into improved care for our patients. The purpose of this study was to determine if these advances have made a difference in our outcomes in patients treated for complicated appendicitis.

Subjects and Methods

A retrospective review of 169 patients undergoing laparoscopic appendectomy in 2009 was performed. Of these, a subset of 50 patients was identified with complicated appendicitis. Complicated appendicitis was defined as either gangrenous or perforated appendicitis. Demographic data, operative findings, postoperative morbidity, operative time, and hospital length of stay were tabulated. These findings were compared with findings from a similar cohort of 34 patients reported previously from 1995. ¹⁵ Statistical analysis was performed using Fisher's exact test with a .95 confidence level for statistical significance.

Results

During a 9-month period in 2009, 169 laparoscopic appendectomies were performed for acute appendicitis. Fifty of these patients were identified as having complicated appendicitis, defined as gangrenous (25 patients) or perforated (25 patients).

In the gangrenous appendicitis group, there were 14 males and 11 females with an age range of 10–77 years and an average age of 38.4 years. Average operating time was 63 minutes (ranging from 28 to 89 minutes). Hospitalization averaged 1.36 days and ranged from 0 to 5 days. Postoperative morbidity included one wound infection (4%) and one intraabdominal abscess (4%).

In the perforated appendicitis group, there were 13 males and 12 females with an age range of 10–83 years and an average age of 44.6 years. Average operating time was 79 minutes (ranging from 47 to 158 minutes). Hospitalization averaged 2.1 days and ranged from 0 to 4 days. Patients with perforated appendicitis received intravenous antibiotics while hospitalized and were discharged on oral antibiotics and instructed on precautions for infectious complications. They had routine follow-up 1 week after dismissal. Morbidity in perforated appendicitis included 4 patients with intraabdominal abscesses (16%).

These data are compared with the data collected previously from 1995 in Tables 1 and 2. In order to mimic the analysis performed on the patient data collected in the 1995 study, length of stay data reported do not include days of readmission for the 5 patients with postoperative abscesses. These 5 patients were all re-admitted at a later date 2–28 days after discharge and were treated with percutaneous abscess drainage and thus had added hospitalization from 2 to 6 days.

Discussion

Laparoscopic appendectomy was first reported by Semm in 1981. ¹⁶ Since that original work, several studies have been published purporting the advantages of laparoscopic appendectomy. In 1994, we published our results with a prospective randomized comparison of open versus laparoscopic appendectomy. ⁵ We found that the laparoscopic technique produced less pain, shorter hospitalization, and quicker return to full activities. Several other studies have found similar results.

The treatment of complicated appendicitis by laparoscopic appendectomy has not met with the same degree of acceptance. Several studies have shown an increased complication rate following laparoscopic appendectomy for gangrenous or perforated appendicitis. In 1996, we published our laparoscopic appendectomy results for complicated appendicitis, which demonstrated significantly higher complication rates than those seen with uncomplicated appendicitis. ¹⁵

Since that study, several advances have occurred in the surgical technique and postoperative care for laparoscopic appendectomy. The use of surgical staplers for the base of the appendix has largely replaced endoloops. A metanalysis of four prospective randomized trials on stump closure during laparoscopic appendectomy was reported by Kazemier et al. ¹⁷ It compared endoscopic linear staplers with loop ligatures. They found that the endoscopic staplers decreased operating time and diminished the rates of wound infection and postoperative ileus. ¹⁷ They concluded that stump closure favors the use of the endoscopic stapler. The laparoscopic endoscopic stapler was not available for use in our prior review from 1995, and the stump of the appendix was routinely ligated with chromic endoloops. In our more recent analysis, the endoscopic stapler was used to divide and close the appendiceal base. Operating time shows a trend toward shortening in gangrenous appendicitis. No significant difference was seen in perforated appendicitis. This likely reflects the complex dissection that is often required in complicated appendicitis that is the primary determinant of operating time in this operation. In addition, as these operations were performed in a teaching setting, there exists an ongoing learning curve for residents performing the procedure.

Another technical advance that occurred during the time between our two study groups was the development of the laparoscopic extraction bag. In our earlier study, the appendix was removed through the 10-mm Hasson trocar without wound protection. The potential for intraabdominal and wound contamination existed with this technique. In our later group, the appendix was routinely placed in an extraction bag as soon as it was divided from the cecum. We saw a trend toward decreased infectious complications that did not reach statistical significance, especially in the group of perforated appendicitis. This could reflect our small sample size and warrants further study. Wound infections, however, decreased from 10% to 0%, and intraabdominal abscesses were reduced from 26% to 16%.

In a retrospective review of their experience with laparoscopic appendectomy, Gupta et al. ¹⁸ discussed the importance of surgical technique in reducing infectious complications. They stated that wound protection is “essential” and recommended use of an extraction device. The authors also commented upon the importance of following “basic surgical tenets” such as use of atraumatic graspers, avoidance of operative rupture of the appendix, and limited irrigation of the periappendiceal tissues to prevent spread of bacterial contamination. We agree with these principles and feel it has helped to lower our infectious complications.

A significant difference that was noted between the two study periods was in length of stay, from an average of 7 to 2.1 days in perforated appendicitis. The use of oral combinations of quinolones and oral anaerobic coverage or oral penicillins combined with beta-lactamase inhibitors offers good therapeutic coverage in an oral route. Over the years between the two study groups, our transition from parenteral to oral antibiotics has shortened to where our practice is to make that transition as soon as the patient can tolerate oral intake. Often this is on postoperative Day 1. This enables the patients' antibiotic regimen to be continued as an outpatient. Outpatient communication and scheduled follow-up are imperative as this group of patients continues to be at risk for infectious complications following dismissal.

It is difficult from our review to determine which of these advances in the last 15 years has had the biggest impact on patient care. But clearly, ongoing advances have translated into improved care for our patients. This review demonstrates a trend toward fewer infectious complications while producing a statistically significant shortening of hospital stay.